Fundamentals Exam #1 Flashcards
Identify the normal defenses of the body against infection
Skin — 1st line of defense, shedding outer layer of skin cells, sebum; mechanical barrier to microorganisms + antibacterial activity
Mouth — multilayered mucosa, saliva
Eyes — tearing, blinking
Respiratory tract — cilia lining upper airways, coated by mucus, macrophages
Urinary tract — flushing action of urine flow, intact multilayered epithelium
GI tract — acidity of gastric secretions, rapid peristalsis in small intestine
Vagina — @ puberty normal flora cause vaginal secretions to achieve low pH
Discuss the development of the inflammatory response
Purpose of inflammation: protective vascular rxn involving cascade of physiological responses to neutralize and eliminate pathogens/necrotic tissues, establishes a means of repairing body cells and tissues
1) Redness
2) Warmth
3) Pain
4) WBC count increases
5) Fever
Exudate: purulent drainage; serous or sanguineous exudates
Tissue repair: tissue defects heal and close
Immune response: when a foreign material (antigen) enters the body, a series of responses changes the biological makeup of the body; the next time the same antigen enters, antibodies bind to the antigens, neutralize, destroy, and eliminate
Assess patients at risk for acquiring an infection
— Immunocompromised when immune system is impaired
— Chemotherapy
— Organ transplant anti rejection medictions
— AIDS
Explain conditions that promote development of health care–acquired infections (HAIs)
— Invasive procedures, medical therapies, long hospitalizations, and contact with health care personnel
— Lowered resistance to infection due to underlying medical conditions
— Invasive treatment devices
— Treatments with multiple antibiotics for long periods of time
— Hands of healthcare workers
— Body excretions
— Secretions of patients, equipment, and healthcare environment
Types of HAIs vs. Asepsis
HAIs
— Exogenous—from microorganisms outside the individual
— *Endogenous *—when the patient’s flora becomes altered and an overgrowth results
_____________
Asepsis
— Absence of disease-producing microorganisms
— Medical asepsis
— Surgical asepsis
The number of microorganisms needed to cause an HAI depends on
— The virulence of the organism
— The susceptibility of the host
— The body site affected
Describe strategies for standard precautions
STANDARD — provide protection for everyone that may transmit something
e.g. blood products, all bodily fluids, secretions, excrements touch your hand
_____________
CONTACT
______________
DROPLET
_______________
AIRBORNE
What do I need to protect myself?
In what order would you prepare to enter the room of a patient in contact and droplet isolation precautions for MRSA?
1. Put on Eyewear
2. Perform Hand Hygiene
3. Put on Gloves
4. Put on Mask
5. Put on Gown
2, 5, 4, 1, 3
To decrease the risk of a urinary tract infection while a patient has an indwelling urinary catheter, what should the nurse do?
1. Encourage fluids before the insertion of the catheter and while the catheter is in place
2. Make sure the catheter and insertion supplies remain sterile throughout the insertions procedure
3. Place the urine collection bag higher than the bladder to maintain patency of drainage tubing
4. Secure the catheter tubing to the patient’s thigh
5. Assess the patient’s history of latex allergy
1, 2, 4
Which of the steps are designed to control the portal of entry of a microorganism (SATA)?
1. Scrub the hub of an IV tubing port before inserting a safety needle
2. Wearing PPE
3. Frequent oral hygiene
4. Daily bathing with chlorhexidine gluconate
5. Keep point of connection between urinary catheter and drainage tube closed
Describe the Five Moments for Hand Hygiene
Purpose: hands are not visibly soiled, you may use an alcohol-based hand rub to decontaminate the hands in the following situations
- Before touching a patient
- Before clean/aseptic procedure
- After body fluid exposure risk
- After touching a patient
- After touching patient surroundings
Perform proper procedures for hand hygiene
Has 4 techniques —
**1) Hand washing
2) Antiseptic hand wash — washing with warm H20 + water
3) Antiseptic hand rub
4) Surgical hand antisepsis
NOTE: hand washing does NOT kill microorganisms, it decreasing the amount of microorganisms
Describe the steps for applying personal protective equipment
DONNING (put on) PPE
Gloves
Respirator (mask)
Eeyes (goggles)
Gown
DOFFING (take off) PPE
Gown
Eyes
Rloves
Mask
NOTE: Hand hygiene is to be performed before donning and after doffing PPE
Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure
Assess Body Temperature:
Temperature = back of hand
Moisture = palm of hand
Pulse:
Respiration:
O2 saturation:
Blood Pressure (BP):
Describe factors that cause variations in vital signs
— frequent pain and/or discomfort
— temperature of environment
— physical exertion
— effects of Dx’c tests and illnesses
— physical and physiological stress
— medical and nursing therapies
Identify ranges of acceptable vital sign values for an infant, child, and adult
Infant
Temp:
HR: 120-160
RR:
BP: 65/41
________________
Toddler
Temp:
HR: 90-140
RR:
BP: 86/40
_________________
Preschool child
Temp:
HR: 80-110
RR:
BP: 94/56
__________________
School-aged child
Temp:
HR: 75-100
RR:
BP: 103/62
__________________
Adolescent
Temp:
HR: 60-90bpm
RR:
BP: 110/65
__________________
Adult
Temp: 36-38C (oral, healthy) | 35-36.1C (oral, o. adult)
HR: 60-100
RR:
BP: <120/80
What are factors that influence HRs?
Exercise
Temperature
Emotions
Medications
Hemorrhages
Postural changes
Pulmonary conditions
Explain variations in techniques used to assess vital signs in an infant, child, and adult
Infant
— pull down on pinna if <3 years old
Child
— if >3 years old, pull up on pinna
Adult
What are the signs + symptoms for when inflammation becomes systemic?
Fever, leukocytosis, malaise, anorexia, nausea, vomiting, and lymph node enlargement.
Identify the physiological processes of ventilation, perfusion, cardiac output, and respiratory gas exchange
Describe the interrelationship of cardiac output, preload, afterload, contractility, and heart rate
Describe the effects of a patient’s health status, age, lifestyle, and environment on tissue oxygenation
Identify and describe clinical outcomes for hyperventilation, hypoventilation, and hypoxemia
Describe the role of the musculoskeletal and nervous systems in the regulation of activity and exercise
Discuss physiological and pathological influences on body alignment and joint mobility
Describe how to assess patient body alignment and levels of activity and exercise
Formulate nursing diagnoses for patients experiencing alterations with activity and exercise
Develop an individualized nursing care plan for a patient with impaired physical mobility
Describe the concepts of mobility and immobility
Discuss the physiological and psychosocial changes associated with immobility and identify the impact changes have on nursing interventions
Explain the techniques for assessing body alignment and impaired mobility
Identify appropriate nursing diagnoses for patients with impaired mobility
Describe environmental hazards that pose risks to patient safety
Discuss the importance of national patient safety resources and standards for promoting patient safety
Describe factors that create a culture of safety
Describe the nurse’s role in prevention of serious reportable events
Identify relevant nursing diagnoses associated with risks to safety
Explain approaches for establishing a restraint-free environment
Identify factors to consider in the use of restraints
Describe factors that influence personal hygiene practices
Perform a comprehensive assessment of a patient’s hygiene needs
Discuss appropriate interventions for hygiene problems
Explain the importance of foot care for a patient with diabetes
Discuss conditions that place patients at risk for impaired oral mucous membranes
Describe how hygiene for older adults differs from hygiene for younger patients
Describe the structure and function of the cardiopulmonary system
- Identify the physiological processes of ventilation, perfusion, cardiac output, and respiratory gas exchange
- Describe the interrelationship of cardiac output, preload, afterload, contractility, and heart rate
- Describe the electrical conduction system of the heart
- Describe the effects of a patient’s health status, age, lifestyle, and environment on tissue oxygenation
- Describe clinical outcomes as a result of disturbances in conduction, altered cardiac output, impaired valvular function, myocardial ischemia, and impaired tissue perfusion
- Identify nursing interventions for promotion, maintenance, and restoration of cardiopulmonary function in all health care settings
- Identify and describe clinical outcomes for hyperventilation, hypoventilation, and hypoxemia
Exam Concepts
What to/not to do?
— Problems with prolonged immunity
— Sources of protein/ nutritional servings per day
— Fall risk assessment
— Isometric exercises
— Cane ambulating
— Agitated client safety
— Hand hygiene
— Ergonomics in lifting
— Biohazard
— Crutch gait
— WBC labs
— PPE donning/doffing
— MRSA transmission
— W/C safety
— TB
— Fall
— Fires
— Restraints
Problems with prolonged immunity
Develop resistant tendencies?
because of hyperactive immune responses your body can’t tell the difference between your healthy, normal cells and invaders. In essence, your immune system turns against you.
Nutrient-dense sources of protein
— Red meat
— Cream soups/meat-based vegetable soups
— Cheese, eggs, peanut butter
— Milk/fortified milk-substitutes w/ Ca + VitD (soy, almond, rice)
— WBC labs —
Ranking WBC differential counts from largest to smallest percentage found in your body
WBC — 5,000-10,000/mm3 — increased = acute infxn
Neutrophils — 55%-70% — acute infxn
Lymphocytes — 20%-40% — bacterial/viral infections
Monocytes — 2%-8% — protozoan, rickettsial, TB infections
Eosinophils — 1%-4% — parasitic infection
”Ew, there’s something inside of me”
Basophils — 0.5%-1% — allergic rxns
_N_ever
_L_et
_M_onkeys
_E_at
_B_ananas
NOTE: Bone marrow not waiting for the baby neutrophils to mature, so sending them out to fight the infx = VERY SICK = bandemia/left-shift
Isometric exercises
Involve tightening or tensing muscles without moving body parts (isometric contraction)
e.g. holding a bicep curl, wall squat
Why? ideal for patients who do not tolerate increased activity
Crutch Gait
— The basic crutch stance is the tripod position, formed when the crutches are placed 15 cm (6 inches) in front of and 15 cm to the side of each foot
What is the chain of infetion?
Infectious agent –> Reservoir –> Portal of Exit –> Modes of Transmission –> Portal of Entry –> Susceptible Host
Bones perform 5 functions in the body
1) Support
2) Protection
3) Movement
4) Mineral storage
5) Hematopoiesis (blood cell formation).
Order: 650mg Tylenol PO q4-6hrs
Available: 325mg tablets
(650mg/325mg) x quantity —> 2 tablets
Practice problem: In 9 hours, what is the intake?
30mL = 1oz
240mL = 8oz
_____________
250mL NS
150mL packed RBC
15mL (=30mL)
8oz OJ
4oz jello
NS @ 75mL/h = x9 = 675mL
___________
TOTAL = 1450mL
Order: 650mg
Available: 325mg/2mL
(650mg/325mg) x 2 = 4mL
