Fund Nur 50 - week 1.1 Flashcards
ISBAR
I—Introduction
S—Situation
B—Background
A—Assessment
R—Recommendation
Q—Question and answer
assessment
identify needs during hygiene, check skin, edema
signs for skin (CTTJB
redness - esp over bony prominences, rash, temp and color, skin trigger, jaundice, cyanosis, ruddy of lower extremities, bruising.
observe patients’ capabilities for hygiene - who is at risk…(PVD for hygiene)
older, bedridden, dementia, immune compromised, diabetes, PVD, dexterity, immobile, arthritis
bathing - don’t make…
assumptions, ask questions
if you delegate to a CNA, you need to make
parameters. Nurses can delegate. You are responsible for the oversight. ex - if a patient has a red area, CNA needs to notify you so you can perform an assessment.
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.
partial bed baths
for patients who are very ill. bathing only body parts that cause discomfort or odor. under arms, under breasts, face, hands
for independent showers, what criteria? (4 things)
1) can patient follow directions, 2) is the patient ambulatory, 3) has a steady gait w/out any dizziness 4) do you have an order for the patient to get up ad lib.
during shower, wear..
PPE
no baby powder
ever, in perineal care. Talc is gone now bc of potential cancer. Corn starch baby powder is contraindicated bc of pulmonary issues, inhilation, etc.
shaving precautions or contraindications
anti-coagulents, bleeding disorder, if so, must use patient’s designated electric shaver. If patient has beard, you need verbal consent to shave it off, and document it as well.
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
reservoir
bacteria can survive, ex. fomite, health care workers’ hands
portal of exit and entry
mouth, wound, gi tract, mucous, respiratory
modes of 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.
try to have patient…
carry out as many activities on their own as possible, but provide assistance if needed.
purpose of bathing (SCIA)
keep skin intact, promote comfort, prevent infection, assess patient.
considerations when performing hygiene (needs)
patient’s preferences, values, and needs. More affluent patient, products might be important. Transient patient - maybe where they’re going to be discharged over the type of product used.
culturally appropriate bathing
some cultures might not bathe for a period of time.
geriatric patients
skin is very delicate, even tape can tear it. if there is a deficit, be careful. chronic illness, diabetes,
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.
some patients don’t have the oxygen stores or energy stores for a
bed bath. You need to assess the patient.
tub or shower is..
most ideal for bathing, but there might be contraindications.
If a patient can shower independently, you need to
escort them to shower, show them where emergency call light is
bag bath
some in warmer or heated up in special microwave. Some you can add the warm water.
evidence based practice tells us that
prepacked baths are preferred bc the studies show lower risk of healthcare infection, decrease microbial count, nurses prefer it bc it’s fast, no reservoir of water in basin, cost of towels and basins, etc.
in prepacked baths, make sure you get
every inch of skin on patient
hair and scalp care
wear gloves bc of the risk of contact w/ something you don’t see. Like breakdown in occipital area.
back rub after
bathing, and apply lotion. You need to review for contraindications before, blood clotting for example.
with foot inspections, often breakdown is observed..
in between toes.
if teeth aren’t cleaned every 2 hours for unconscious patient, they develop
aspiration pneumonia. saliva pools and collects bacteria, they breathe it in.
toothette
lollipop
always remove dentures and inspect for
ulcerations. inspect the gums and clean dentures.
if you have a patient who has oxygen, hearing aid, tube feeding…
check where the contact is to make sure no breakdown.
hold all contaminated materials..
away from you. Open door with elbow.
make sure the bed is..
in the lowest position
make sure the bed position is…
safe for the patient
make sure the bed controls are
functioning (bed is electrically safe)
make sure call light
is functioning and always within reach
make sure side rails are
raised if indicated
make sure the wheel or casters are
locked
infection cycle, or chain of infection. every piece needs…
to be intact to spread infection
in infection, first you need
an infectious agent or pathogen. Could be resident or transient pathogen.
resident pathogen - and how to remove it
something that is embedded in the skin and requires vigorous friction and antimcrobial soaps to remove.
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.
bacteria can be transmitted even if…
the patient is not infected.
people who carry bacteria without evidence of infection (fever, increased wbc) are
colonized
if an infection develops, it is usually from (the colony always infects us)
bacteria that colonize patients
bacteria that colonize patients can be transmitted
from one patient to another by the hands of healthcare workers
reservoir (and ex.)
where an organism will thrive and survive, but not necessarily multiply - could be an inanamate object, fomite. food - salmonella in potato salad. healthcare workers hands, nebulizer.
nebulizers have what bacteria? (nebulize pseudos)
pseudomonas.
portal of exit
mouth, wound,
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 - vctors in the air) REMEMBER THIS (and what do you need to wear)
TB, Covid, varicella - need to wear an N95 and negative pressure room.
chains of infection - you need a…
susceptible host. take care with immunocompromised.
we can decrease our susceptibility of infection by..
getting vaccines.
if fire, RACE
Rescue anyone in immediate danger
Activate the fire code system and notify the appropriate person
Confine the fire by closing doors and windows
Evacuate patients and other people to a safe area
restraints (#1 most important)
1) determine need
2) secure order
3) hand hygiene and PPE
4) id patient
5) explain reason for restraint
6) include patient family
7) choose least restrictive restraint, pad bony prominences, wrap restraint around extremity
8) secure in place w/ velcro etc.
9) 2 fingers under strap
10) use quick release knot on bedframe
11) perform hand hygiene
12) check on patient every hour
13) remove restraint every 2 hours
ISBAR
I - intro - Amanda, nursing student
S - calling about ellen scheduled for surgery. She’s having doubts.
B - admitted yesterday, positive for cancer.
A - more than just gitters
R - should I hold the pre-op?
R - I understand you want me to hold the pre-op meds.
SOAPIE (soap is subjective)
subjective, objective, assessment, plan, implement, evaluate
I in ISBAR
I—Introduction: People involved in the handoff identify themselves, their roles, and their jobs
B in ISBAR (what it entails)
B—Background: Vital signs, mental and code status, list of medications, and lab results
S in ISBAR
S—Situation: Complaint, diagnosis, treatment plan, and patient’s wants and needs
A in ISBAR
A—Assessment: Current provider’s assessment of the situation
R in ISBAR
R—Recommendation: Identify pending lab results and what needs to be done over the next few hours and other recommendations for care
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
